1. Introduction
Nursing staff, including registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs) are the primary caregivers in nursing homes and are critical to delivering high quality care [
1]. However, high turnover rates among nursing staff have been a long-standing concern in nursing homes [
2]. A recent study using data from the national-level Payroll-Based Journal (PBJ) reported alarmingly high median turnover rates of 102.9% for RNs, 79.8% for LPNs, and 98.8% for CNAs [
3]. Although turnover rates reported in other recent studies vary [
4,
5]—largely due to inconsistent definitions of turnover—nursing staff turnover remains a salient issue that demands attention.
Nursing staff turnover can adversely affect nursing home performance. For instance, turnover has been associated with a higher number of quality of care deficiencies and increased mortality among nursing home residents [
6,
7]. A study by Zheng and colleagues [
5] has reported that nursing staff turnover may be associated with poorer quality outcomes such as increased emergency department visits and a reduced likelihood of achieving higher star ratings in the Care-Compare: Five-Star Quality Rating System (Five-Star QRS).
Furthermore, increased turnover can also be financially burdensome for nursing homes due to the significant expenses associated with recruiting, hiring, and training new employees. These costs can include advertising job openings, conducting interviews, onboarding, and dedicating time and resources to training [
4]. Such expenses can divert resources away from other critical investments, such as improving resident services and maintaining overall care quality [
8].
Prior research has linked nursing staff turnover to various factors such as job design [
9], facility characteristics such as quality [
3,
10], leadership turnover [
11], organizational commitment [
12], job satisfaction [
13], and wages [
4]. However, little is known about how nursing staff patterns, such as the use of agency labor, influence turnover.
Agency or contract staff are temporary professionals employed by third-party agencies to fill staffing gaps across various facilities [
14]. In recent years, the use of agency nursing staff has increased significantly in nursing homes, particularly due to staffing shortages precipitated by the COVID-19 pandemic. For instance, in 2018, 23% of nursing homes used agency nursing staff, accounting for 3% of direct care hours. By 2022, nearly half of nursing homes used agency staff, accounting for 11% of direct care hours [
15]. Hiring agency nursing staff offers certain advantages such as flexible scheduling, reduced overtime for regular staff, and decreased need to create permanent positions [
16]. Agency nursing staff can also shield nursing homes from sudden shortages due to absenteeism or a surge of residents [
17].
Despite these benefits, the utilization of agency nursing staff raises concerns about its potential impact on nursing home performance. While prior research has explored associations between agency nursing staff utilization and quality [
18,
19] as well as the ownership factors influencing their use [
17], there is limited understanding of how agency staff utilization influences turnover among permanent staff. This study addresses this gap by investigating the relationship between agency nursing staff utilization and the turnover rates among permanent nursing staff in nursing homes.
Given the acute shortage of nurses in the United States (U.S.) healthcare system, reliance on agency labor is likely to persist for the foreseeable future. Therefore, it is crucial to understand how agency labor affects key nursing home performance metrics, such as turnover. By highlighting these important dynamics, the findings of this study may help policymakers and nursing home administrators better understand the implications of agency nursing staff utilization on nursing home performance. Ultimately, the findings could inform strategies to sustain high-quality care while addressing the challenges of workforce retention.
3. Results
The final analytic data file comprised 35,200 nursing homes with an average of 11,733 unique facilities per year.
Table 1 provides descriptive statistics summarizing the key variables and highlights significant changes between 2021 and 2023. Turnover rates increased significantly across all nursing staff types. For RNs, turnover rose from 63.1% to 87.7%, for LPNs from 42.4% to 64.6%, and for CNAs from 49.1% to 67.1% (
p < 0.001). The proportion of agency nursing staff hours PRD increased significantly: for RNs, it rose from 6.2% to 8.9%, for LPNs from 8.9% to 11.6%, and for CNAs from 7.4% to 9.3% (
p < 0.001). Nursing hours PRD decreased slightly for RNs and LPNs but remained stable for CNAs, with only the changes for RNs and LPNs being significant (
p < 0.001). Quality ratings also shifted significantly, with an increase in facilities rated with one or two stars and a decrease in those rated five stars (
p < 0.001).
The fixed-effects regression analysis showed that high utilizers of agency labor experienced significantly higher nursing staff turnover rates (
Table 2). High agency utilizers had approximately a 7.7% higher turnover compared to low utilizers among RNs (
p < 0.001). Similarly, high utilizers of agency CNAs experienced a 1.9% higher turnover among permanent CNAs (
p < 0.05). However, the analysis found no significant impact of high agency LPN utilization on LPN turnover.
In addition to agency staff utilization, several covariates were examined for their association with turnover rates. Higher occupancy rates and increased nursing staff hours PRD were consistently associated with lower turnover across all staff types (p < 0.001). Additionally, higher quality (star ratings) corresponded to reduced LPN turnover, with five-star facilities showing approximately a 9.1% lower turnover (p < 0.001). In contrast, a higher Medicare Advantage rate was linked to a 1.2% higher CNA turnover rate (p < 0.001).
4. Discussion
Nursing staff are critical to nursing home performance, and high turnover rates have been a long-standing concern in the industry. As nursing homes increasingly turn to agency nursing staff to address staffing gaps, understanding the implications of these staffing dynamics is essential. This study aimed to evaluate the relationship between the use of agency nursing staff utilization and turnover rates in nursing homes. It compared facilities having high reliance on temporary nursing staff with those having lower reliance to determine if greater utilization leads to increased staffing instability.
In this study, the relationship between agency nursing staff and turnover appeared to be nuanced, having varying effects across different types of nursing staff. The findings suggest that the most significant influence was observed among RNs, where higher utilization of agency RNs was significantly associated with increased turnover. In contrast, the impact on CNAs was smaller, while no significant relationship was found for LPNs.
Broadly speaking, there are many reasons why agency nursing staff may be associated with higher turnover. As agency nursing staff may be unfamiliar with the facility’s protocols, residents’ specific needs, and the organizational culture [
19], they can create an additional workload for the permanent staff [
29]. The permanent staff may need to assist or supervise agency labor, leading to increased stress and job dissatisfaction. A survey conducted among nursing home administrators revealed that increased supervision is one of the most frequently reported disadvantages of using agency nursing staff [
29]. This added responsibility can contribute to burnout and a desire to leave the organization [
13].
Furthermore, an overt reliance on agency nursing staff may signal to the permanent staff that the facility is not invested in long-term staffing solutions. This perception can diminish morale and organizational commitment among permanent staff, factors previously associated with turnover [
12]. Moreover, agency labor can hinder the development of strong team dynamics and trust among staff members. This may be particularly acute when agency labor becomes a semi-permanent substitute for directly employed labor, as is increasingly apparent in some nursing homes [
15].
Additionally, agency labor is significantly more expensive than regular nursing staff; for instance, in 2022, agency RNs in nursing homes cost almost
$24 more per hour than directly employed RNs [
30]. These significant salary differentials may fuel discontent among the permanent staff, leading to higher turnover. Equity theory suggests that employees assess fairness by comparing their input–output ratios to those of their peers; perceived inequities can lead to decreased job satisfaction and increased turnover intentions [
31]. Permanent nursing staff may believe that the resources devoted to hiring agency labor could have been invested in retention strategies, such as competitive salaries, benefits, or professional development opportunities. Finally, the use of agency nursing staff has been linked with lower quality in nursing homes [
18], which can be demoralizing for permanent staff committed to providing high-quality care. Research suggests that lower quality nursing homes may experience higher turnover [
3].
Turning to the specific findings of this study, the most pronounced impact was observed among the RNs, where higher reliance on agency RNs strongly correlated with increased RN turnover. RNs are the cornerstone of nursing home quality and hold critical roles in resident care coordination, clinical decision-making, infection prevention and control, and leadership within the care team [
1]. Introducing agency RNs, who may be less familiar with the facility’s protocols and resident-specific care plans, may lead to inconsistencies in care delivery. Permanent RNs may experience increased workloads as they assist agency RNs in acclimating to the facility’s environment, which can lead to job dissatisfaction and burnout.
Moreover, RNs possess advanced skills and qualifications that make them highly sought after across various healthcare settings, especially given their acute shortage in the U.S. healthcare system [
32]. For instance, hospitals typically offer higher salaries, better benefits, and more opportunities for professional development compared to nursing homes [
33,
34]. The higher job mobility means that when permanent RNs face disruptions in their work environment due to high use of contractual labor, they may be more inclined to seek employment elsewhere. Furthermore, the need to frequently integrate agency RNs might hinder the development of cohesive teams, affecting communication and trust among staff members and further motivating permanent RNs to seek outside opportunities.
In contrast, the utilization of agency CNAs appeared to exert a relatively modest impact on turnover among permanent CNAs. CNAs are primarily responsible for providing direct resident care, assisting with the activities of daily living, and addressing the needs of cognitively challenged residents [
1,
35]. Given that CNAs already experience high baseline turnover rates in nursing homes [
3], the additional impact of agency CNAs may be less material. While the use of agency CNAs may introduce some challenges, permanent CNAs might be more adaptable to working alongside agency staff due to the task-oriented nature of their roles [
36]. However, the modest increase in turnover indicates that some level of dissatisfaction or strain exists, possibly due to inconsistencies in care approaches or increased responsibilities in guiding agency CNAs.
Finally, the absence of a significant relationship between agency LPN utilization and LPN turnover is an interesting finding that warrants further research. LPNs often occupy a middle ground between RNs and CNAs, performing duties that include administering medications and monitoring resident conditions [
1]. As LPNs operate under the supervision of RNs, the nature of their work may involve more standardized procedures, making it easier for agency LPNs to integrate within the care team without causing significant disruption. Additionally, other factors not captured in this study, such as job satisfaction levels or career advancement opportunities, may play a more significant role in influencing LPN turnover.
An interesting finding of this study was that increased nursing staff hours were consistently associated with lower turnover rates across all categories. Adequate staffing ratios can alleviate the workload on individual caregivers, reduce job-related stress, and enhance job satisfaction [
37]. CMS has finalized new nursing home staffing requirements, including a minimum of 0.55 RN hours PRD [
38]. While these regulations have faced legal challenges [
39], our study findings indicate the importance of enhanced nursing staff hours in nursing homes, which may reduce turnover and, in turn, improve quality.
This study has several limitations. The observational design does not establish causality, and it is possible that higher turnover rates drive the increased use of agency nursing to fill staffing gaps, creating a feedback loop that complicates the interpretation of results. Although the facility-level fixed-effects model helps account for time-invariant characteristics or within-facility variation, it does not address the concern of reverse causality. Future researchers should consider employing more advanced techniques, such as instrumental variable approaches, to better address this issue and strengthen causal inferences. Second, the lack of consistent definition of turnover in literature may complicate comparisons across studies. Variability in how turnover is defined and measured can impact the generalizability of our findings and may contribute to differences observed in turnover rates reported by other studies. This inconsistency underscores the need for standardized definitions and measures of turnover in future research. Third, the data used in this analysis were not specifically collected to study turnover, which may limit the precision of the turnover variable. Missing data may also introduce biases, as facilities with incomplete data might differ systematically from those with complete records; however, given the large sample size, this is unlikely to be a significant concern. Fourth, confounding variables, such as leadership styles, job satisfaction, organizational culture, and work environment characteristics, were not captured or controlled for in this analysis. These unmeasured factors may have influenced both turnover rates and agency nursing staff utilization, potentially introducing bias. Future research should evaluate the wage gap between agency nursing staff and permanent staff to understand how it mediates turnover. Finally, we lack information on the tenure of nursing staff and the type of departure (voluntary or involuntary). This information is important to fully understand the dynamics of turnover in nursing homes. Thus, there is a need to conduct qualitative studies focused on understanding the specific reasons for staff separations in nursing homes.
Policy and Practical Implications
The sharp growth of agency nurses in NHs has offered a seemingly convenient solution to address chronic nursing staff shortages. Our results underscore the potential pitfalls of this approach, as it may be associated with increased turnover among the nursing staff.
Efforts to reduce reliance on agency nurses by improving the recruitment and retention of permanent nurses could also be beneficial. However, addressing the structural issues behind the U.S. nursing shortage will require significant policy interventions and is unlikely to materialize in the short term. In the interim, agency nurses are a reality. Therefore, targeted interventions such as competency assessments and fostering collaborative opportunities that harness their potential while safeguarding nursing home performance are crucial. Policymakers can play a significant role by incentivizing stable staffing models through financial incentives, enacting stricter qualification and training standards for agency nursing staff, and ensuring adequate funding for long-term care workforce development [
35]. Collaboration between nursing home leaders and policymakers is crucial to implement these strategies effectively and to promote a sustainable, high-quality workforce that meets resident needs.
These results have important implications for staffing strategies in nursing homes. High turnover among the nursing staff and the use of agency labor are inextricably linked; however, there is no single solution or one-size-fits-all approach to address this issue. To mitigate high rates of turnover among licensed nurses such as RNs, facilities should provide a supportive work environment that includes elements such as “the implementation of evidence-based practices; shared decision making regarding resident care, staffing, and the work environment, involvement, and leadership in quality improvement initiatives; and support for professional development” [
35].
While strategies for licensed nurses should focus on creating a supportive professional environment, CNAs face different challenges that may require alternative approaches. Despite the arduous nature of their work, CNAs receive low wages and frequently lack benefits, resulting in poverty-level incomes [
35,
40]. Research suggests that improved CNA wages and the provision of health insurance benefits may be associated with reduced turnover [
4,
41]. Nursing homes should also consider providing additional training for CNAs including career advancement and professional development opportunities, as these are not only associated with higher quality [
42] but also with higher job satisfaction [
43]. Moreover, given that nurse aides are disproportionately women from minority backgrounds, it is important to address existing disparities related to institutional racism and sexism [
44,
45].
